Brig Royd Osteoporosis Protocol

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Brig Royd Osteoporosis Protocol
(Updated December 2014)
Osteoporosis is defined as systemic skeletal disorder, characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and
susceptibility to fracture
DEXA definition - A ‘T-score’ of ≥ 2.5 standard deviations (SD) below the young adult mean has
been classified as osteoporosis by the World Health Organisation (WHO). Overall fracture risk
increases two-fold per unit SD decrease in BMD and this relationship is even greater for hip fractures
and BMD measured at hip sites. In terms of T scores, a score of -2.5 or less confirms osteoporosis,
between -1 and -2.4 confirms osteopaenia.
Identifying patients at high risk of osteoporosis
Clinical risk factors:

Age

Gender

Low BMD

Previous fragility #

Parental history of hip #

BMI < 19

Hormonal – premature menopause, prolonged amenorrhoea (not related to PCOS or
pregnancy), use of depot provera > 5 years. Includes men post-orchidectomy/androgen
deprivation/hypogonadism

Drugs – oral steroids (any dose of oral corticosteroids for >3/12 OR 1 g Prednisolone or equiv.
lifetime dose.) GnRH analogues, arimidex, anticonvulsant therapy, Glitazones, PPIs

Lifestyle – smoking and alcohol intake (>3 units/day), immobility,

Medical conditions – rheumatoid arthritis, IBD, Malabsorption, cystic fibrosis,
hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, vit D insufficiency, COPD, Type
1 DM, Chronic renal and hepatic disease.
Consider using Qfracture - http://www.qfracture.org/index.php (or FRAX via systmone)
Primary Prevention

Women aged < 45 with recent premature menopause = HRT until 52 (unless
contraindicated). Not for DEXA unless other risk factors

Women aged > 50 and Men aged > 65 who have clinical risk factors:

FRAX calculation


o
Low risk (<10%)– lifestyle advice, consider Qfracture repeat after 5
years unless risk factors change
o
Higher risk (>10%) – DEXA referral
DEXA PIL http://www.patient.co.uk/health/dexa-scan
Frail/>75 with clinical risk factors

Falls assessment

Check Vit D and calcium and consider further investigation if an underlying cause
suspected. (e.g FBC, ESR, Electrolytes, Bone profile, TFTs, PTH, ALP, Coeliac
screening)

Treat without DEXA (as per 2° prevention)
PMR
Individuals > 65 or hx of prior fragility fracture - DEXA not required use bisphosphonate and calcium
& vitamin D
Individuals < 65 - Start calcium & vitamin D, DEXA scan and consider bisphophonate if T score less
than -1.5
Secondary prevention
(1) Women aged > 50 or men aged >65 with low trauma fracture

DEXA referral

Follow scan report recommendations
(2) If abnormal DEXA but no history of #

FBC, ESR, Electrolytes, Bone profile, TFTs, PTH, ALP, Coeliac screening, Oestrodiol
(amenorrhoeic pre-menopausal), testosterone (men), Vit D

Follow scan report recommendations.
Treatments in order of preference: (from NOGG and NICE)
(1) Alendronate (once weekly)
(2) Risedronate (once weekly prep) – n.b ?often better tolerated and now off
patent, but still second line as per NICE – (?likely to change with next guidance)
(3) Consider ibandronate (once monthly)
(4) Strontium (caution re VTE/CVD) – see link below; these patients should be
reviewed every 6 months to reassess vascular risks
(5) Raloxifene - not licensed for primary prevention, but is for secondary prevention
in certain circumstances ( BNF osteoporosis treatment)
All plus calcium/vit D – Calderdale formulary recommends generic coleclciferol
400unit/Calcium carbonate 1.5g chewable tablets BD (equivalent of adcal D3)
If none of above tolerated – refer to rheumatology for advice. (?denosumab/teriparatide)
PIL for patients on different treatments in osteoporosis (National Osteoporosis Society)
Repeating DEXA - In line with PACE guidance (&BMJ) patients with osteoporosis should have a scan
every 3 years and those with osteopaenia every 5 years. (please create patient alert with date of
next DEXA and consider adding reminder to repeat prescriptions)
Brig Royd Codes to use.
(1) Referral for DEXA =
/dexa
(2) Fragility fracture =
/fracture
(3) T score =
/dexat
(4) Osteoporosis =
/osteo
QOF 2015/16; unchanged ( but remember to code DEXA results if osteoporotic as well as fragility
fracture)
OST001
OST002
OST003
The contractor establishes and maintains a register of patients:
1. Aged 50 or over who have not attained the age of 75 with a record of a fragility
fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA
scan, and
2. Aged 75 years or over with a record of a fragility fracture on or after 1 April 2012
The percentage of patients aged 50 or over who have not attained the age of 75,
with a fragility fracture on or after 1 April 2012, in whom osteoporosis is confirmed
on DXA scan, who are currently treated with an appropriate bone-sparing agent.
The percentage of patients aged 75 or over with a fragility fracture on or after 1
April 2012, who are currently treated with an appropriate bone-sparing agent.
links for more info
http://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!scenario
http://www.osteoporosis-resources.org.uk/
http://www.shef.ac.uk/NOGG/NOGG_Pocket_Guide_for_Healthcare_Professionals.pdf
http://www.nos.org.uk/page.aspx?pid=264&srcid=234
DRUG HOLIDAYS
The following guidance is taken from the National Osteoporosis Society and seems to be in line with
current practice.
Bisphosphonates have a long half-life in bones and their effects continue for some years after
stopping.
Due to concerns about atypical femoral fractures and osteonecrosis of the jaw a drug holiday should
be considered after 5 yrs of treatment.
Some patients may require long term treatment ( eg patients with multiple v ertebral fractures,
treatment with high dose steroids, or patients with very low BMD at outset).The benefits are likely
to outweigh the risks.
NOGG guidance suggests a review of patients after 5 years treatment with alendronate or
risedronate. This review should include the re-assessment of fracture risk in treated individuals using
the FRAX tool, combined with a repeat DEXA as necessary, before deciding if continuing treatment is
appropriate.
Arrange DEXA after 5 yrs of treatment.



If BMD same/improved/>2.5 withdraw treatment for 2-3 years then reassess with DEXA
Fracture risk should be reassessed after any new fracture or every 2 years. Consider
restarting treatment if fracture risk increases.
If fracture risk is still above the intervention threshold; continue treatment for another 5 yrs.
DENOSUMAB
This is now under shared care scheme and GP responsibilities include





Ensure compliance with vitamin D/ calcium
Have recall system for 6 monthly injection
Early treatment of skin infections/cellulitis which is an increased risk.
Delay any invasive dental treatment until just before 6 monthly injection
Refer back to specialist after 5 years.
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